How to Integrate PQRI Measures Into Practice

June 2007

By Christie L. Carter
ACEP News Contributing Writer

As the Physician Quality Reporting Initiative's first official reporting period of July 1 to Dec. 31 draws near, ACEP NEWS took the opportunity to explore some of PQRI's more technical aspects with Susan Nedza, M.D., M.B.A. In her role at the Special Program Office, Value Based Purchasing at the Centers for Medicare and Medicaid Services, Dr. Nedza co-leads education and outreach activities in support of PQRI. She also serves as the chief medical officer for Region V of CMS.

ACEP NEWS also sought Dr. Nedza's expertise to better understand how the measures work, as well as recommendations for implementing the measures into your practice of emergency medicine.

ACEP NEWS: First, the question that's looming in the minds of some emergency physicians: Will the cost of reporting outweigh the benefit of PQRI's bonus, and are there other reasons that physicians should participate in the initiative?

Dr. Nedza: Physicians should consider PQRI in the context of payer transformation. As Medicare transitions from rewarding volume of services to paying for efficient, quality patient care, this is but one small step.

What's important is the value it provides to patients. If PQRI enables a group to improve the rate of administration of ASA or beta-blockers in acute MI, improves the care of patients with community-acquired pneumonia, or if one EKG is ordered on a patient with nontraumatic chest pain or syncope that saves a life or averts a liability case, then it's worth it.

A second major benefit is the value of their commitment to measuring quality within the hospital setting. CMS is moving forward on pay for performance for hospitals, and ED groups that participate in PQRI are showing their commitment to the relationship.

ACEP NEWS: Why is the July 1 start date so important, and if emergency physicians cannot be ready to begin reporting on that date, what is their "next-best" option?

Dr. Nedza: The bonus payment is calculated based upon all claims submitted during the July-December reporting period, so the later that emergency physicians begin submitting codes, the more difficult it will be to qualify for the bonus. However, it's never too late to start, and there is no penalty for missing the start date. Even if they don't qualify for the bonus, the effort to improve quality and the experience gained in reporting quality data codes will be valuable.

ACEP NEWS: How does the 2007 program address some emergency physicians' concerns that they have little or no control over a variety of measures that include emergency department E/M codes?

Dr. Nedza: The codes were developed with, by, and for emergency physicians. I recommend that emergency physicians look at the broad list of codes available and choose those that will be easiest to implement. For instance, codes that reward ordering a medication or a test fall within physicians' control.

ACEP NEWS: How can emergency physicians work to "operationalize" their PQRI reporting between now and July 1, and what advice can you offer to help them integrate these measurements into their practice?

Dr. Nedza: Here is a suggested model to assist emergency physicians in their efforts:

Visit the PQRI Web site and download the measures and specifications.

Read the guidance that ACEP has issued regarding measure selection.

Meet as a group and select at least three measures that make sense for your patient population.

Examine how eligible patients will be identified, and modify the medical record or utilize a worksheet to capture the actions required (i.e., EKG ordered for nontraumatic chest pain).

Consider how this action will be captured for the coding and billing process (flow sheet, modified EMR, modified template, etc.).

Consider using worksheets developed for CMS by the AMA (available in early June).

Work with your coding and billing entity to ensure that quality data codes are captured and submitted with claims.

ACEP NEWS: Can you elaborate on why the modifiers are important to the practice of emergency medicine?

Dr. Nedza: The use of CPT II codes and modifiers gives practices the ability to monitor adherence to guidelines and protocols. It also allows them to gain an understanding of when deviation due to clinical judgment or physician reason occurs (1P), due to patient reasons such as refusal or lack of resources (2P), and due to system reasons, such as a lack of resources. The reporting modifier (8P) also allows groups to audit when emergency physicians don't document deviation from a clinical guideline. This is important for risk management and improving compliance with recommended care.

ACEP NEWS: Do you have any closing thoughts for our readers?

Dr. Nedza: High-quality emergency care is practiced in a team environment. As CMS and other payers move to reward high-quality, efficient care, emergency physicians have the ability to influence those choices.

In the end, it's all about what happens at the bedside over 100 million times each year. When emergency physicians follow the guidelines developed by our peers, change their processes to capture appropriate variation from those guidelines based upon patient need, and identify barriers in their local environment that impact the care they deliver, they're fulfilling their professional role.

Participating in PQRI will have a positive impact on each patient who seeks care in the emergency department.

A wealth of PQRI-related information, including a list of frequently asked questions, is available online at

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